Natalie Carvalho

Characterizing the epidemiological transition in Mexico: national and subnational burden of diseases, injuries, and risk factors.

Background Rates of diseases and injuries and the effects of their risk factors can have substantial subnational heterogeneity, especially in middle-income countries like Mexico. Subnational analysis of the burden of diseases, injuries, and risk factors can improve characterization of the epidemiological transition and identify policy priorities. Methods and Findings We estimated deaths and loss of healthy life years (measured in disability-adjusted life years [DALYs]) in 2004 from a comprehensive list of diseases and injuries, and 16 major risk factors, by sex and age for Mexico and its states. Data sources included the vital statistics, national censuses, health examination surveys, and published epidemiological studies. Mortality statistics were adjusted for underreporting, misreporting of age at death, and for misclassification and incomparability of cause-of-death assignment. Nationally, noncommunicable diseases caused 75% of total deaths and 68% of total DALYs, with another 14% of deaths and 18% of DALYs caused by undernutrition and communicable, maternal, and perinatal diseases. The leading causes of death were ischemic heart disease, diabetes mellitus, cerebrovascular disease, liver cirrhosis, and road traffic injuries. High body mass index, high blood glucose, and alcohol use were the leading risk factors for disease burden, causing 5.1%, 5.0%, and 7.3% of total burden of disease, respectively. Mexico City had the lowest mortality rates (4.2 per 1,000) and the Southern region the highest (5.0 per 1,000); under-five mortality in the Southern region was nearly twice that of Mexico City. In the Southern region undernutrition and communicable, maternal, and perinatal diseases caused 23% of DALYs; in Chiapas, they caused 29% of DALYs. At the same time, the absolute rates of noncommunicable disease and injury burdens were highest in the Southern region (105 DALYs per 1,000 population versus 97 nationally for noncommunicable diseases; 22 versus 19 for injuries). Conclusions Mexico is at an advanced stage in the epidemiologic transition, with the majority of the disease and injury burden from noncommunicable diseases. A unique characteristic of the epidemiological transition in Mexico is that overweight and obesity, high blood glucose, and alcohol use are responsible for larger burden of disease than other noncommunicable disease risks such as tobacco smoking. The Southern region is least advanced in the epidemiological transition and suffers from the largest burden of ill health in all disease and injury groups.

Priority setting for health interventions in Mexico's System of Social Protection in Health

Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria--eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households--to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.

Alternative Strategies to Reduce Maternal Mortality in India: A Cost-Effectiveness Analysis

A cost-effectiveness study by Sue Goldie and colleagues finds that better family planning, provision of safe abortion, and improved intrapartum and emergency obstetrical care could reduce maternal mortality in India by 75% in 5 years.

Intervention strategies to reduce the burden of non-communicable diseases in Mexico: cost effectiveness analysis

Objective To inform decision making regarding intervention strategies against non-communicable diseases in Mexico, in the context of health reform. Design Cost effectiveness analysis based on epidemiological modelling. Interventions 101 intervention strategies relating to nine major clusters of non-communicable disease: depression, heavy alcohol use, tobacco use, cataracts, breast cancer, cervical cancer, chronic obstructive pulmonary disease, cardiovascular disease, and diabetes. Data sources Mexican data sources were used for most key input parameters, including administrative registries; disease burden and population estimates; household surveys; and drug price databases. These sources were supplemented as needed with estimates for Mexico from the WHO-CHOICE unit cost database or with estimates extrapolated from the published literature. Main outcome measures Population health outcomes, measured in disability adjusted life years (DALYs); costs in 2005 international dollars (

Definición de prioridades para las intervenciones de salud en el Sistema de Protección Social en Salud de México

Int); and costs per DALY. Results Across 101 intervention strategies examined in this study, average yearly costs at the population level would range from around ≤

More evidence on the impact of India's conditional cash transfer program, Janani Suraksha Yojana: quasi-experimental evaluation of the effects on childhood immunization and other reproductive and child health outcomes.

Int1m (such as for cataract surgeries) to >

Expenditures and Prices of Antihyperglycemic Medications in the United States: 2002-2013

Int1bn for certain strategies for primary prevention in cardiovascular disease. Wide variation also appeared in total population health benefits, from <1000 DALYs averted a year (for some components of cancer treatments or aspirin for acute ischaemic stroke) to >300 000 averted DALYs (for aggressive combinations of interventions to deal with alcohol use or cardiovascular risks). Interventions in this study spanned a wide range of average cost effectiveness ratios, differing by more than three orders of magnitude between the lowest and highest ratios. Overall, community and public health interventions such as non-personal interventions for alcohol use, tobacco use, and cardiovascular risks tended to have lower cost effectiveness ratios than many clinical interventions (of varying complexity). Even within the community and public health interventions, however, there was a 200-fold difference between the most and least cost effective strategies examined. Likewise, several clinical interventions appeared among the strategies with the lowest average cost effectiveness ratios—for example, cataract surgeries. Conclusions Wide variations in costs and effects exist within and across intervention categories. For every major disease area examined, at least some strategies provided excellent value for money, including both population based and personal interventions.

National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan

La definicion explicita de prioridades en intervenciones de salud representa una oportunidad para Mexico de equilibrar la presion y la complejidad de una transicion epidemiologica avanzada, con politicas basadas en evidencias generadas por la inquietud de como optimizar el uso de los recursos escasos para mejorar la salud de la poblacion. La experiencia mexicana en la definicion de prioridades describe como los enfoques analiticos estandarizados en la toma de decisiones, principalmente los de analisis de la carga de la enfermedad y de costo-efectividad, se combinan con otros criterios -tales como dar respuesta a las expectativas legitimas no medicas de los pacientes y asegurar un financiamiento justo para los hogares-, para disenar e implementar un grupo de tres paquetes diferenciados de intervenciones de salud. Este es un proceso clave dentro de un conjunto mas amplio de elementos de reforma dirigidos a extender el aseguramiento en salud, especialmente a los pobres. Las implicaciones mas relevantes en el ambito de politicas publicas incluyen lecciones sobre el uso de las herramientas analiticas disponibles y probadas para definir prioridades nacionales de salud; la utilidad de resultados que definan prioridades para guiar el desarrollo de capacidades a largo plazo; la importancia de favorecer un enfoque para institucionalizar el analisis ex-ante de costo-efectividad; y la necesidad del fortalecimiento de la capacidad tecnica local como un elemento esencial para equilibrar los argumentos sobre maximizacion de la salud con criterios no relacionados con la salud en el marco de un ejercicio sistematico y transparente.

VITALITY trial: protocol for a randomised controlled trial to establish the role of postnatal vitamin D supplementation in infant immune health

Background In 2005, India established a conditional cash transfer program called Janani Suraksha Yojana (JSY), to increase institutional delivery and encourage the use of reproductive and child health-related services. Objective To assess the effect of maternal receipt of financial assistance from JSY on childhood immunizations, post-partum care, breastfeeding practices, and care-seeking behaviors. Methods We use data from the latest district-level household survey (2007–2008) to conduct a propensity score matching analysis with logistic regression. We conduct the analyses at the national level as well as separately across groups of states classified as high-focus and non-high-focus. We carry out several sensitivity analyses including a subgroup analysis stratified by possession of an immunization card. Results Receipt of financial assistance from JSY led to an increase in immunization rates ranging from 3.1 (95%CI 2.2–4.0) percentage points for one dose of polio vaccine to 9.1 (95%CI 7.5–10.7) percentage points in the proportion of fully vaccinated children. Our findings also indicate JSY led to increased post-partum check-up rates and healthy early breastfeeding practices around the time of childbirth. No effect of JSY was found on exclusive breastfeeding practices and care-seeking behaviors. Effect sizes were consistently larger in states identified as being a key focus for the program. In an analysis stratified by possession of an immunization card, there was little to no effect of JSY among those with vaccination cards, while the effect size was much larger than the base case results for those missing vaccination cards, across nearly all immunization outcomes. Conclusions Early results suggest the JSY program led to a significant increase in childhood immunization rates and some healthy reproductive health behaviors, but the structuring of financial incentives to pregnant women and health workers warrants further review. Causal interpretation of our results relies on the assumption that propensity scores balance unobservable characteristics.

Capturing Budget Impact Considerations Within Economic Evaluations: A Systematic Review of Economic Evaluations of Rotavirus Vaccine in Low- and Middle-Income Countries and a Proposed Assessment Framework

A recent study demonstrated widespread substitution of analog for human insulin and rising out-of-pocket costs in privately insured people with type 2 diabetes in the United States.1 Medicaid reimbursements have increased for both human insulin and more costly analog insulins.2 Although studies have described per-person changes in excess medical spending of US adults with diabetes on prescription medications,3 they have not reported trends in expenditures for different classes of antihyperglycemic medications that simultaneously consider changes in use and price.